Partner notification, a component of sexually transmitted
disease
(STD) control programs for many years (1), is a means to identify
and
target risk-reduction education to individuals at high risk for
contracting or transmitting HIV infection. When applied to HIV
infection, the term "partner" includes not only sex partners but
also
intravenous drug users who share needles. Partner notification for
HIV
infection or acquired immunodeficiency syndrome (AIDS), as for all
STDs, is highly confidential and depends upon the voluntary
cooperation of the patient. CDC currently recommends the
following:
"Persons who are HIV-antibody positive should be instructed in how
to
notify their partners and to refer them for counseling and
testing. If
they are unwilling to notify their partners or if it cannot be
assured
that their partners will seek counseling, physicians or health
department personnel should use confidential procedures to assure
that
the partners are notified" (2).

Two complementary notification processes can be used to
identify
partners, patient referral and provider referral. With patient
referral, HIV-infected patients choose to inform their own
partners
directly of their risk of infection. Trained health department
personnel can help instruct patients how to inform sex and needle-
sharing partners sensitively about their potential risk for
infection.
With provider referral, infected patients request assistance in
notifying some or all of their partners; they voluntarily provide
names, descriptions, and addresses so that the notification
process
can be carried out by trained health department staff. This
process is
designed to protect the anonymity of patients; their names are
never
revealed to sex or needle-sharing partners.

In the AIDS prevention and surveillance projects supported by
CDC,
states have been required to implement procedures for confidential
notification of sex and needle-sharing partners of AIDS patients
and
HIV-seropositive individuals. All these states currently counsel
HIV-infected clients seen in public counseling and testing sites
about
ways to reduce the risk of transmitting HIV. These states also
counsel
HIV-infected clients about the need to inform sex and
needle-sharing
partners of their risk of infection. Forty-eight states, Puerto
Rico,
the Virgin Islands, and the District of Columbia offer provider
referral upon request by clients (Table 1). The other two states
authorize notification by health department personnel when female
partners may not have known that a risk factor existed and/or in
cases
of rape or sexual abuse. Fifteen states have partner-notification
programs that encourage provider referral for all patients.

Data are available to CDC from partner-notification activities
in
four states. Colorado emphasizes provider referral as the
preferred
method for notifying all sex and needle-sharing partners of
HIV-infected individuals. From January 1986 through December 1987,
282
index patients were offered partner-notification services. They
identified 508 partners, of whom 414 (81%) were located; of these
414,
44 (11%) had previously tested positive for HIV antibody and were
not
contacted. Of the remaining 370 identified partners, 296 (80%)
underwent counseling and testing; 74 (20%) were counseled but
refused
testing. Forty-five (15%) of those 296 newly tested were positive
for
HIV antibody. None had previously been reported to the state.

Idaho has instituted a partner-notification program that
emphasizes provider referral. Of 120 HIV-positive index patients
identified since the program began in 1985, 97 (81%) have received
counseling about partner notification. These patients requested
assistance to notify 118 partners. Fifty-nine partners (50%) were
located, and all accepted counseling and testing; 23 (39%) were
found
to be infected with HIV.

In 1987, South Carolina initiated partner-notification
activities
emphasizing provider referral. In one rural county where only one
case
of HIV infection and no cases of AIDS had been previously
reported, 90
sex partners, 69 of whom were county residents, were named by a
single
HIV-infected homosexual male (3). Of the 68 county residents who
consented to testing, 12 partners (18%) were infected with HIV.

Virginia currently provides partner-notification services to
HIV-infected patients who request assistance with notifying
certain
partners. From September 1986 through December 1987, 387 (81%) of
the
479 individuals who tested positive for HIV antibody at STD
clinics
returned for test results and were offered partner-notification
services. Of these, 230 patients (59%) chose provider referral to
notify their partners. A total of 318 partners were located and
accepted counseling and testing; 44 (14%) were found to be
positive
for HIV infection. In addition to being sex or needle-sharing
partners
of HIV-infected persons, 38 (87%) of the infected partners
belonged to
other high-risk groups: 72% were at risk through
homosexual/bisexual
behavior, and 15% through intravenous drug use.
Reported by: TM Vernon Jr, MD, FC Wolf, MPA, NE Spencer, RE
Hoffman,
MD, MPH, State Epidemiologist, Colorado Dept of Health. JB Perry,
CD
Brokopp, DrPH, State Epidemiologist, Idaho Dept of Health and
Welfare.
RF Wykoff, MD, SL Hollis, RN, ST Leonard, RN, CB Quiller, CW Heath
Jr,
MD, Acting State Epidemiologist, South Carolina Dept of Health and
Environmental Control. CW Riley, AM Cader, MD, GB Miller Jr, MD,
State
Epidemiologist, Virginia State Dept of Health. Div of Sexually
Transmitted Diseases, Center for Prevention Svcs, CDC.
Editorial Note: Partner notification, with emphasis on provider
referral, became an integral strategy for national syphilis
control in
the mid-1940s after penicillin became widely available.
Subsequently,
it has been used in STD control programs for gonorrhea and
chlamydia
(1,4). Provider referral has been shown to be effective, but
costly
(5), in controlling focal outbreaks of infections due to
antibiotic-resistant gonococcal strains (6) and in targeting
endemically infected core groups in specific high-risk populations
(7,8). Because of resource limitations, patient referral, rather
than
provider referral, has played an increasingly important role in
STD
control.

When the partner-notification model is applied to the control
of
HIV infection, certain differences must be considered. The
incubation
period for HIV is long; therefore, sex partners or needle-sharing
partners from months or years earlier may potentially have been
the
sources of infection. Partner notification for patients with
hepatitis
B, which has an epidemiologic pattern similar to that of HIV
infection, has proven difficult because of the prolonged period of
infectivity, the large number of anonymous sex partners among many
homosexual men, and the inaccessibility of the intravenous
drug-using
population (9).

The assurance of confidentiality and protection against
discrimination, which are critical in dealing with any STD, have
become legal issues in the case of HIV infection (10,11). These
issues
may influence the success of programs based on patient referral
alone
(12). Confidentiality is essential to ensure that individuals at
risk
continue to seek counseling, testing, or partner-notification
services.

Partner-notification data from several states reveal a high
seroprevalence rate, ranging from 11% to 39%, among persons
identified
as sex or needle-sharing partners, many of whom are themselves
engaging in high-risk behavior. By identifying such individuals,
the
partner-notification process can target risk-reduction messages to
those at greatest risk of acquiring or transmitting infection.
Thus,
partner notification provides both primary and secondary
prevention of
HIV infection.

Notification of unsuspecting partners is especially important
because it enables persons who may not have been reached through
other
AIDS education programs to receive risk-reduction education. For
example, the partner-notification process can identify female and
male
partners of intravenous drug users or female partners of bisexual
males who may have been exposed to HIV infection but who may be
unaware of their risk. Partner-notification activities targeted
toward
women of childbearing age contribute additionally by potentially
preventing the perinatal transmission of HIV (13).

Homosexual men who voluntarily request counseling and HIV
testing
may be at lower risk for infection than those who have refused
testing
(14). Through the partner-notification process, these high-risk
partners who otherwise might not request risk-reduction education
can
receive counseling. Also, counseling of partners provides an
opportunity to offer other beneficial services to those at risk,
including drug treatment, STD treatment, tuberculosis testing and
treatment, adult immunizations, psychosocial support services, and
contraceptive counseling.

The type of partner-notification services provided by
different
health departments will depend on local resources and the number
of
seropositive persons identified. In San Francisco, which has high
rates of infection among homosexual men, provider referral for all
partners of homosexual men was not thought to be feasible because
of
the excessive cost and personnel required. However, the San
Francisco
Health Department did notify heterosexual sex partners of AIDS
patients and received excellent cooperation from both patients and
named partners (15). The San Francisco experience demonstrates the
feasibility of targeted notification for identifying infected
women of
childbearing age to prevent perinatal transmission of HIV
infection.

State and local health departments are encouraged to develop
evaluation programs to identify the most effective
partner-notification strategies for different clinical and
sociocultural settings in both areas with high and low HIV
seroprevalence rates.
References

Woo JM, Neal DP, Geoghegan CM, et al. Evaluation of
heterosexual
contact tracing of partners of AIDS patients (Abstract no.
6002).
In: Final program and abstracts of the IV International
Conference
on AIDS. Book 1. Stockholm, Sweden: Swedish Ministry of Health
and
Social Affairs, National Bacteriological Laboratory,
Karolinska
Institute, World Health Organization, 1988:354.

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